Every finding on record at Hospice of Pamlico County, Inc

Based on agency policy, clinical record review, and staff interviews, the agency failed to complete dressing changes on an implanted port and care as ordered in the plan of care for 1 of 1 patient with a continuous infusion via implanted port [implanted device for medication administration]. (patient #1)Findings included: --- A policy, Continuous Infusion via Implanted Port (revised 2/2017), received on 3/23/26 at 2:23 PM from the agency director stated, “Review the doctor’s orders for infusion via IVAD [Continuous Infusion via Implanted Port].Patient #1 was admitted on 12/13/26 with diagnoses of basal cell carcinoma of the skin (skin cancer) and secondary neoplasm of the bone (skin cancer that has spread to the bones). The plan of care for 12/13/26-3/12/26 included orders for skilled nurse visits 2 times a week for 13 weeks with 10 PRN (as needed), and “Maintain implanted port access with Huber needle [specialized needle to access implanted ports]. Change needle and dressing weekly and PRN occlusion, leakage, or dislodgement. Flush per agency policy.” Review of the clinical record revealed that there was no documentation of the IVAD care being completed for weeks 1, 2, and 3 (12/13/26-1/15/26).During an interview conducted on 3/23/26 at approximately 3:00 PM the agency director stated, “It was an oversight” and confirmed that IVAD care had not been completed. The expectation is for the skilled nurses to review the plan of care orders before seeing a patient.

Based on clinical record review, and staff interviews, the registered nurse failed to document hospice health aide (HHA) supervisory visits every 14 days for 1 of 1 patient receiving HHA services. (patient #3)Findings included: --- Patient #3 was admitted on 1/20/26 with a diagnosis of rectal cancer. The plan of care for 1/20/26-4/29/26 included orders for skilled nurse visits 1 time a week for 13 weeks with 10 PRN (as needed) and HHA visits 1 time a week for 13 weeks. Review of the clinical record revealed that no HHA supervisory visits were conducted between 1/20/26 and 3/17/26.During an interview conducted on 3/23/26 at 11:46 AM RN #4 stated, “Aide supervisory visit are done every 14 days with the comp [comprehensive assessment].An interview conducted on 3/23/26 at 11:55 AM with the agency director revealed that the expectation is for supervisory visits to be completed and documented at least every 14 days.

Based on agency policy review, clinical record review, and staff interview, the agency failed to conduct an initial bereavement assessment for 1 of 4 records reviewed for an initial bereavement assessment (Patient #4). Findings included: --- An undated agency policy titled; ";Bereavement Services" was received from the agency director on 10/18/23 at 3:52 PM. This policy revealed, ";Counseling extends to residents and employees of a SNF/NF [skilled nursing facility/nursing facility] ...when appropriate and identified in the bereavement plan of care." Patient #4 was admitted to the agency 06/09/23 with a principal diagnosis cerebral infarction (stroke). The plan of care beginning 06/09/23 revealed orders for skilled nursing one time per week and medical social worker two times per month. Employee #5, medical social worker, conducted the social worker assessment on 06/12/23. There was no evidence of an initial bereavement risk assessment in Patient #4s record. In an interview on 10/17/23 at 11:10 AM, Employee #1, agency director, stated, ";She [Patient #4] was a ward of the state...I will let my social worker answer that question." In an interview on 10/17/23 at 12:25 PM, Employee #5, medical social worker, stated that she was unable to locate an initial bereavement risk assessment in Patient #4s clinical record.

Based on agency policy, clinical record review, and staff interviews the agency failed to include Full Code (resuscitation procedures to keep the patient alive) status for 1 of 3 patients that remained a Full Code. (Patient #7) Findings included: --- A policy, Care Planning (not dated) was received on 10/18/2023 at approximately 3:00 P.M. from the agency director. The policy stated, "All documentation in the patient's clinical record will reflect direction of patient/family." Patient #7 was admitted on 02/15/2023 with a diagnosis of malignant neoplasm (cancer) of the rectum. The plan of care (POC) for 08/13/2023 - 10/12/2023 included orders for registered nurse (RN) visits 1 time a week, social worker visits 2 times a month, and Do Not Resuscitate (DNR). Five of 5 medical social worker visits included evidence of patient #7 having a DNR (Do not Resuscitate) order. Eight of 9 nurse visits included evidence of patient #7 having a DNR order. For the registered nurse (RN) visit of 10/12/2023 RN #3 stated, the patient "is not a DNR." An interview was conducted with RN #2 on 10/17/2023 at approximately 2:30 P.M. RN #2 stated, "We have been discussing the code status at IDG [Interdisciplinary group] for weeks. I talked to [agency director's name] about it. I should have changed the code status the day I noticed it." An interview was conducted with the agency director on 10/17/2023 at approximately 2:45 P.M. The agency director stated, " From February 28th through October 12th the chart for [patient #7 name] stated that there was a DNR. She was never a DNR."

Based on agency policy, clinical record review, and staff interviews the agency failed to include the visit frequency and plan of care for volunteer services for 1 of 1 patient with a volunteer visit. (Patient #13) Findings included: --- A policy, Care Planning (not dated) was received on 10/16/2023 at approximately 3:30 P.M. The policy stated, "The care plan shall include: Types and frequency of services required to meet the goals... interventions to be performed by each discipline. An interview was conducted on 10/18/2023 at approximately 3:30 P.M. The agency director stated that volunteer visit frequencies should be included in the plan of care.

Based on agency policy review, clinical record review, and staff interview, the agency failed to include enteral (an artificial opening into the stomach or intestines) feeding orders on the plan of care for 1 of 2 patients receiving enteral feedings (Patient #1). Findings included: --- An agency policy titled; ";Care Planning" and dated 07/2007, was received from the agency director on 10/16/23 at 3:00 PM. This policy revealed, ";The care plan will be established by the Interdisciplinary Team [IDT] and in accordance with the orders of the attending physician at start of care" and ";The care plan shall include...types and frequency of services required to meet the goals...interventions to be performed by each discipline..." Patient #1 was admitted to the agency 04/28/23 with a primary diagnosis malignant neoplasm of accessory sinus (cancer of the sinus). Plan of care from 04/28/23 to 05/12/23 revealed orders for registered nurse two times per week and hospice aide two times per week. Documented care plan issues included tube feedings with the goal ";Patient should maintain optimal nutritional level for disease process" and the intervention to ";Monitor PEG [percutaneous endoscopy gastrostomy or tube placed in the stomach or intestines that is used for feeding] insertion site for signs and symptoms of infection." There was no documentation on the plan of care that included the type or frequency of feeding for Patient #1. In an interview on 10/18/23 at 2:55 PM, Employee #1 stated, ";We didnt have anything on the tube feeding."

Based on agency policy, QAPI (Quality Assurance and Performance Improvement) review, and staff interviews, the agency failed to show measurable improvement indicators as a part of the QAPI program. Findings included: --- A policy, Quality Assessment and Performance Improvement (QAPI) (no date) was received on 10/18/2023 at approximately 2:11 P.M. from the agency director. The policy stated, "The program [QAPI] will be capable of showing measurable improvement..." A review of the agencys QAPI plan was conducted. There was no evidence of the agency monitoring for improvement or effectiveness of the QAPI plan. An interview with the agency director on 10/18/2023 at approximately 3:45 P.M. revealed that the agency has no performance improvement plans.

Based on agency policy, QAPI (Quality Assurance and Performance Improvement) review, and staff interviews, the agencys governing body failed to participate in QAPI plans. Findings included: --- A policy, Quality Assessment and Performance Improvement (QAPI) (no date) was received on 10/18/2023 at approximately 2:11 P.M. from the agency director. The policy stated, ";The governing body will ensure the following:..." A review of the agencys QAPI plan was conducted. There was no evidence of the agencys governing body being involved with review of quality indicators or implementation and review of performance improvement plans. An interview with the agency director on 10/17/2023 at approximately 2:00 P.M. revealed that the governing body was not involved with performance improvement.

Based on observation, agency policy, and staff interviews the agency failed to comply with infection control standards for 1 of 3 patients with home visits. (Patient #8) Findings included: --- A policy, Infection Control (not dated) was received on 10/16/2023 at 3:00 P.M. from the agency director. The policy stated, "Detailed infection control education, based on CDC [Center for Disease Control] recommendations, will be provided." CDC Hand Hygiene Guidance (reviewed 01/2020) stated, "Recommendations of the Healthcare Control Practices Advisory Committee include the following strong for hand hygiene... Before moving from work on a soiled body site to a clean body site, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal." Patient #8 was admitted on 09/06/2023 with a diagnosis of Alzheimer's Disease. The plan of care for 09/06/2023 - 12/04/2023 included an order for Hospice Aide (HHA) visits 2 times a week. Patient #8 resides in a skilled nursing facility. A home visit was conducted on 10/17/2023 at 10:00 A.M. with HHA #4. HHA #4 provided care to the genital area and failed to perform hand hygiene prior to handing the bed controls. HHA #4 failed to perform hand hygiene after providing rectal care before placing a clean brief on patient #8. HHA #4 failed to perform hand hygiene after removing the soiled linens. An interview was conducted with HHA #4 on 10/17/2023 at approximately 11:00 A.M. HHA #4 stated, "I was nervous and would normally wash my hands more often." An interview was conducted with the agency director on 10/17/2023 at approximately 1:30 P.M. The agency director stated, "The aide [HHA #4] should have washed her hands."

Based on agency policy review and staff interview, the agency failed to offer bereavement services to the employees and residents of a contracted skilled nursing facility (SNF #1). Findings included: --- An undated agency policy titled; ";Bereavement Services" was received from the agency director on 10/18/23 at 3:52 PM. This policy revealed, ";Counseling extends to residents and employees of a SNF/NF [skilled nursing facility/nursing facility] ...when appropriate and identified in the bereavement plan of care." Patient #4 was admitted to the agency 06/09/23 with a principal diagnosis cerebral infarction (stroke). The plan of care beginning 06/09/23 revealed orders for skilled nursing one time per week and medical social worker two times per month. There was no evidence that bereavement services were offered in Patient #4s record. In an interview on 10/17/23 at 11:10 AM, Employee #5, medical social worker, asked, ";Should I provide bereavement to the people at the facility?" and stated that she was unaware of the requirement to offer bereavement support to facility residents and personnel.

Based on agency policy review, clinical record review, and staff interview, the agency failed to produce a discharge order for 1 of 2 live discharge records reviewed (Patient #1) and failed to provide a discharge summary for 2 of 2 live discharge records reviewed (Patient #1 and Patient #2). Findings included: --- An undated policy titled, ";Discharge for Reason Other Than Death" was received from the agency director on 10/18/23 at approximately 4:00 PM. This policy revealed, ";When the IDT [interdisciplinary team] determines that a patient should be discharged for reasons other than death...the Medical Director gives the order to begin discharge procedure...a copy of the discharge summary will be sent to the attending physician..." 1. Patient #1 was admitted to the agency 04/28/23 with a primary diagnosis malignant neoplasm of accessory sinus (cancer of the sinus). The plan of care from 04/28/23 to 05/12/23 revealed orders for registered nurse two times per week and hospice aide two times per week. Patient #1s clinical record indicated that she had been discharged from the agency on 05/12/23. Further examination of the clinical record revealed that on 05/22/23, Employee #1, agency director, sent a certified letter to Patient #1s responsible party informing the responsible party that Patient #1 had been discharged as of 05/12/23 due to an inability to reach the caregiver and make nursing visits. There was no discharge order or discharge summary in Patient #1s record at the time of survey. In an interview on 10/17/23 at 12:40 PM, Employee #1 stated ";We [the interdisciplinary group] talked about the management of the patient [Patient #1] ...I sent them a letter informing them of discharge for cause." Employee #1 was unable to locate any additional discharge documents related to Patient #1s discharge. 2. Patient #2 was admitted to the agency 07/20/23 with a primary diagnosis chronic obstructive pulmonary disease (COPD). The plan of care from 07/20/23 to 09/12/23 revealed orders for registered nurse one time per week, hospice aide two times per week, and medical social worker with no documented frequency. Patient #2s record indicated that he had been discharged on 09/12/23. Further examination of the clinical record revealed that on 09/12/23, Employee #1, agency director, Employee #4, hospice aide, and Employee #5, medical social worker, conducted a joint visit and ultimately called 911 when it was identified that Patient #2 was in ";excruciating pain" and did not have an available caregiver. EMS (Emergency Medical Services) transported Patient #2 to the local hospital and where he was admitted. There was no discharge summary in Patient #2s record at the time of survey. In an interview on 10/18/23 at 11:35 AM, Employee #5 stated that she and Employee #1 were not able to locate any additional discharge documents related to Patient #2s discharge.